Field-Based Care Coach – Senior Care Coordination

Conviva Senior Primary Care; Lake Park (FL); Hybrid; USD 54,000 - 73,000; Full time

Benefits offered by this job

Sign-on bonus $2,500

Job summary

Conviva Senior Primary Care seeks a Care Coach to provide proactive, patient-centered care coordination for the highest risk top 5% patient membership. You will serve as the primary contact for patients and focus on care coordination, adherence coaching, navigation, transitions of care, and reinforcing care plans.

You report to a Care Integration Team Manager within the CenterWell and Conviva organization. This role has a mobile presence with travel to patients’ homes, clinics and community

Qualifications

• Healthcare professional with 3+ years of ambulatory or senior-care patient care.
• Ability to discuss chronic conditions and reinforce medication instructions.
• Comfort with regular home visits and community outreach.
• Experience in patient education, care coordination, and social support for high‑risk populations.
• Licensed or certified in applicable nursing or medical field; bilingualism preferred.

Responsibilities

• Coordinate care across health and social services as patient advocate and clinician support.
• Perform structured interviews, collect health-related data, and share findings with providers.
• Conduct home visits to assess living conditions and environmental factors.
• Identify barriers to care and connect patients with community resources.
• Deliver chronic disease education using approved materials to reinforce care plans.
• Serve as liaison between patients, primary care, specialists, pharmacists, and home health.
• Support care transitions and schedule follow-ups; discuss and escalate discrepancies.
• Encourage engagement with community programs and deliver culturally sensitive care.
• Participate in High-Risk Rounds to develop comprehensive patient plans.

Skills

Clinical experience

Patient education

Home visits

Education

LPN/LVN license or MA Certification

RN license or equivalent foreign license

Job description

Conviva Senior Primary Care seeks a Care Coach to provide proactive, patient-centered care coordination for the highest risk top 5% patient membership. You will serve as the primary contact for patients and focus on care coordination, adherence coaching, navigation, transitions of care, and reinforcing care plans.

You report to a Care Integration Team Manager within the CenterWell and Conviva organization. This role has a mobile presence with travel to patients’ homes, clinics and community